260 ‒ Men’s Sexual Health: why it matters, what can go wrong, and how to fix it

KEYPOINTS

• 01

  ED is common and largely untreated because of silence on both sides.

  Khera, a Baylor urologist specialising in sexual medicine, cites a 1994 study finding about 52% of men over 40 have some ED. A rough rule: 40% at 40, 50% at 50, 60% at 60. He attributes this to accumulating health conditions more than age itself. In a recent survey of 1,500 men, about 40% had some sexual dysfunction, but only 51% had told their doctor and 44% their partner, mostly out of embarrassment. Busy primary-care doctors rarely ask. About a third of men with ED report depression and 37% anxiety because of it.

• 02

  First, tell psychological from physical ED.

  Two screening questions: can you get an erection firm enough for penetration, and can you keep it until orgasm? Normal morning erections or erections during masturbation suggest a psychological cause, common in younger men, where anxiety ('I hope I don't lose it') becomes self-fulfilling. Khera uses sex therapy and daily tadalafil 5 mg to break the cycle, then often stops it. Physical causes follow the mnemonic VENT: vascular, endocrine, neurologic, trauma, plus medications like beta blockers and finasteride.

• 03

  Most physical ED starts as a 'venous leak.'

  Erections depend on nitric oxide and cGMP; PDE5 inhibitors stop the enzyme that breaks cGMP down. As erectile muscle atrophies and scars with age (low testosterone and disuse contribute), the tissue can't press the veins closed, so blood flows in but won't stay. PDE5 drugs raise inflow to overcome the leak; constriction bands reduce outflow. Avanafil has the least effect on related enzymes (PDE6 affects vision, PDE11 the back) but isn't generic.

• 04

  Khera prescribes daily tadalafil as both prevention and treatment.

  An as-needed pill treats one night while the disease progresses. Studies he cites suggest daily low-dose tadalafil helps maintain erectile muscle, and improved blood-vessel function persisted after stopping in a study by Aversa. 5 mg daily equals roughly 8 mg in steady state (a 1.6× multiplier). It's also FDA-approved for enlarged prostate, without the retrograde ejaculation of Flomax. Don't take it close to Flomax, which can drop blood pressure. Generic tadalafil can cost about $17 for 90 pills.

• 05

  ED is an early warning of heart disease.

  In the Prostate Cancer Prevention Trial follow-up by Ian Thompson (2004), 15% of men who developed ED had a heart attack or stroke within seven years. In another study, about 50% of men with a cardiac event had ED roughly 39 months earlier. Endothelial dysfunction is the shared mechanism. In Esposito's 2004 JAMA trial of 110 obese men, a Mediterranean diet plus exercise raised ED scores by about 3 points without medication. Attia sees erections improve when patients' HbA1c falls from about 5.9 to 5.

• 06

  Peyronie's disease affects 7–9% of men and is usually linked to unnoticed trauma.

  Scar plaque, often on the upper side of the shaft, causes curvature. Above 60° makes intercourse difficult. In the first year, about 15% improve, 40% stay the same and 45% worsen, so Khera waits until it stabilises before surgery. Collagenase injection (Xiaflex, 2015) is the first FDA-approved drug; vitamin E and colchicine don't work. The RestoreX traction device, used 30 minutes twice daily for 3 months, improved curvature 30–40% and can add up to about 2 cm in length (off-label, about $500). In a 2009 study, 74% of Peyronie's patients had low testosterone.

• 07

  Testosterone: treat symptoms, not just a number, and protect fertility.

  Khera says total testosterone stays fairly flat in healthy men as they age, while SHBG rises and free testosterone falls. He prefers calculated free testosterone and notes androgen-receptor sensitivity varies genetically. He and Attia both decline to treat patients without symptoms. For injections he uses 50 mg cypionate under the skin twice a week (Sunday/Thursday, about $25/month), which causes less blood thickening than large doses every two weeks. Clomid raises levels but blocks estrogen, which men need for libido, in about 40%. Low-dose HCG (500 IU every other day) alongside testosterone helped preserve testicular function in Baylor studies. Nasal testosterone (Natesto) appears not to suppress sperm much.

• 08

  Khera avoids finasteride and considers post-finasteride syndrome real.

  He notes that 5α-reductase also converts progesterone into allopregnanolone, a neurosteroid linked to mood and cognition. In his study of 25 men with persistent symptoms, two died by suicide. He acknowledges this is a minority view, and Attia notes randomised trials or better comparison groups are needed. For enlarged prostate he uses alpha blockers (alfuzosin has the least retrograde ejaculation) or daily tadalafil instead.